Senior Claim Benefit Specialist

Job Description:

  • Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines.
  • Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues.
  • Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience.
  • Reviews pre-specified claims and those that exceed specialist adjudication authority or processing expertise.
  • Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost-containment measures to support accurate claim adjudication.
  • Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.
  • Identifies and reports potential overpayments, underpayments, and other claim irregularities.
  • Performs claim rework calculations as needed.
  • Trains and mentors as needed to enhance team performance and technical proficiency.
  • Conducts outbound calls to obtain required information for claims or reconsideration requests.

Requirements:

  • Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator.
  • Proven success working in a high-volume, production-driven environment.
  • Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.
  • Self-Funding experience (Preferred)
  • DG system knowledge (Preferred)
  • High School Diploma required
  • Preferred Associates degree or equivalent work experience.

Benefits:

  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  • Paid time off
  • Flexible work schedules
  • Family leave
  • Dependent care resources
  • Colleague assistance programs
  • Tuition assistance
  • Retiree medical access
Back to blog